Nokea
A client is scheduled to undergo right axillary-to-axillary artery bypass surgery. Which of the following interventions is most important for the nurse to implement in the preoperative period?
- A. Assess the temperature in the affected area
- B. Monitor the radial pulse in the affected arm
- C. Protect the extremity from cold
- D. Avoid using the arm for a venipuncture
Correct Answer: D
Rationale: Avoiding venipuncture in the affected arm is critical preoperatively to preserve vascular integrity and prevent complications (e.g., hematoma) that could affect the axillary-to-axillary bypass surgery. Monitoring pulses, assessing temperature, and protecting from cold are important but less urgent than preventing vascular trauma.
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Which finding indicates a properly functioning ileal conduit?
- A. Clear urine output.
- B. Mucus in the urine.
- C. Dry stoma site.
- D. No urine output.
Correct Answer: B
Rationale: Mucus in the urine is normal due to the intestinal segment used in the conduit.
Which of the following statements about nasoenteric tubes is correct?
- A. The tube cannot be attached to suction.
- B. The tube contains a soft rubber bag filled with mercury.
- C. The tube is taped securely to the client's cheek after insertion.
- D. The tube can have its placement determined only by auscultation.
Correct Answer: C
Rationale: Nasoenteric tubes are taped securely to the client's cheek to prevent dislodgement. They can be attached to suction, do not typically use mercury today, and placement is confirmed by methods like X-ray, not just auscultation. CN: Physiological adaptation; CL: Apply
A client has been in an automobile accident and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for:
- A. Sudden, sharp chest pain.
- B. Wheezing breath sounds over affected side.
- C. Hemoptysis.
- D. Cyanosis.
Correct Answer: A
Rationale: Sudden, sharp chest pain is a hallmark of pneumothorax due to pleural irritation. Wheezing, hemoptysis, and cyanosis are less specific or occur later.
Which assessment finding is expected in the oliguric phase of acute renal failure?
- A. Weight gain.
- B. Hypotension.
- C. Clear urine.
- D. Low BUN levels.
Correct Answer: A
Rationale: Weight gain occurs due to fluid retention in the oliguric phase.
The client with Addison's disease should anticipate the need for increased glucocorticoid supplementation in which of the following situations:
- A. Returning to work after a weekend.
- B. Going on vacation.
- C. Having oral surgery.
- D. Having a routine medical checkup.
Correct Answer: C
Rationale: Oral surgery is a stressful event requiring increased glucocorticoid supplementation to prevent adrenal crisis.